A comparison of outcome of osteoarticular allograft ......Sarcoma(1998)2,163±170 ORIGINAL ARTICLE A...
Transcript of A comparison of outcome of osteoarticular allograft ......Sarcoma(1998)2,163±170 ORIGINAL ARTICLE A...
Sarcoma (1998) 2, 163± 170
ORIGINAL ARTICLE
A comparison of outcome of osteoarticular allograft reconstruction
and shoulder arthrodesis following resection of primary tumours of
the proximal humerus
L. J. PROBYN,1 J. S. WUNDER,1,2 R. S. BELL,1,2 A. M. GRIFFIN1 & A. M. DAVIS1,3
1University Musculoskeletal Oncology Unit, Mount Sinai Hospital & 2Department of Surgery, University of Toronto &3Departments of Physical Therapy and Surgery and Graduate Departments of Rehabilitation Science and Public Health
Science, University of Toronto, Toronto, Canada
Abstract
Purpose. The purpose of this study was to compare the oncologic, reconstructive and functional outcomes of patients whounderwent osteoarticular allograft reconstruction with those who underwent arthrodesis for a primary malignant bonetumour of the proximal humerus.Patients. Eleven patients were treated with osteoarticular allograft reconstruction of the proximal humerus. Five of thesereconstructions failed, necessitating revision to a secondary arthrodesis. Five patients underwent arthrodesis as a primaryreconstruction, for a total of ten patients in the arthrodesis group.M ethods. End points included local and systemic disease recurrence, complications and functional outcome (measuredusing the 1987 and 1993 Musculoskeletal Tumour Society Rating Scales (MSTS) and the Toronto Extremity SalvageScore (TESS)).Results. One patient died of systemic disease 2 years post-operatively and one patient had an axillary node recurrenceresected 10 months post-operatively and remains free of disease 53 months later. The other 14 patients were alive withno evidence of disease at the time of the last follow-up. Complications after the osteochondral allografts (n 5 11) includedtwo infections, four fractures and three subluxations in eight patients. Six of these patients required removal of theallograft; one had a repeat osteochondral allograft and ® ve were converted to an arthrodesis. Complications afterarthrodesis in the ten patients (® ve primary and ® ve secondary arthrodeses) included two non-unions, one infection andone fracture in three patients. Patients who underwent shoulder arthrodesis scored better in all outcome measures and thiswas statistically signi® cant in the MSTS 1993 (p 5 0.001, Mann± Whitney U Test).Discussion. In this study, there was a trend towards improved function following arthrodesis compared to osteochondralallograft reconstruction following proximal humerus bone tumour resection.
Key words: sarcoma, proximal humerus, reconstruction, outcome, function .
Introduction
Reconstruction of the shoulder following resection
of a primary tumour of the proximal humerus is a
challenging clinical problem, particularly since the
resection may result in de® cits of the deltoid, rotator
cuff, joint capsule, glenoid and scapula. The recon-
structive options following proximal humerus
tumour resection include: preservation of a mobile
glenohumeral joint using a prosthesis, osteoarticular
allograft or an allograft± prosthesis composite;
arthrodesis using an allograft or ® bular transplant;
or, a ¯ ail joint (Tikhoff± Linberg procedure).1 ± 4
When suf® cient deltoid, rotator cuff and joint cap-
sule can be preserved to power the glenohumeral
joint, our group has undertaken reconstruction with
osteoarticular allograft. When insuf® cient soft tis-
sues remain, we have utilized an allograft arthrode-
sis. When resection of the proximal humerus,
glenoid and scapula leaves insuf® cient bone stock to
permit shoulder fusion, the Tikhoff± Linberg pro-
cedure is undertaken to avoid forequarter ampu-
tation whenever possible.5,6
The perceived advantage of an osteoarticular allo-
graft reconstruction compared to shoulder fusion is
based on the potential for improved function due to
a mobile glenohumeral joint. However, there is
often considerable mobility imparted to the upper
extremity by the scapulothoracic joint following
arthrodesis. There is no information in the literature
comparing the results of a mobile shoulder versus
Correspondence to: A. M. Davis, Suite 476, Mount Sinai Hospital, 600 University Avenue, Toronto, Canada M5G 1X5. Tel: 1 1 (416)586-8678 ; Fax: 1 1 (416) 586-8397; E-mail: [email protected].
1357-714 X/98/030163± 08 $9.00 Ó 1998 Carfax Publishing Ltd
164 L. J. Probyn et al.
arthrodesis reconstruction following proximal hu-
merus tumour resection. The purpose of this study
was to compare the oncologic, reconstructive and
functional outcomes of patients who underwent os-
teoarticular allograft reconstruction with those who
underwent arthrodesis for a primary bone tumour of
the proximal humerus.
Methods
Patients were eligible for this study if they had
resection of a primary bone tumour of the proximal
humerus and reconstruction with an osteoarticular
allograft or shoulder arthrodesis. All patients had a
minimum of two years’ follow-up from their index
surgery.
Between 1986 and 1995, eleven patients were
identi ® ed who underwent osteoarticular allograft re-
construction of the proximal humerus. During the
same period, ten patients underwent shoulder
arthrodesis. Five of these ten were initially treated
with an osteoarticular allograft that subsequently
failed. These ® ve patients underwent arthrodesis as
a secondary procedure.
All patients underwent clinical, radiographical
(computerized tomography in the initial years and
then both computerized tomography and magnetic
resonance imaging in the latter years), and patholog-
ical staging prior to surgery.
All resections were classi® ed according to the
system of the Musculoskeletal Tumour Society.7 If
the abductor mechanism (deltoid and rotator cuff)
was intact following tumour resection, the case was
denoted with an A, or a B if the abductor mechan-
ism was disrupted. All of the osteoarticular allografts
were classi ® ed as S345A. At least a portion of the
deltoid was disrupted in all of these cases but the
rotator cuff remained intact. All of the primary
arthrodeses (that is, arthrodeses done immediately
following tumour resection, rather than to salvage a
failed osteochondral allograft reconstruction) were
classi® ed as S345B and had resection of their rota-
tor cuff and joint capsule as well as the deltoid.
Reconstructive procedures
Tumour resection was performed following ac-
cepted oncologic principles aiming for negative op-
erative margins. The status of the abductor
mechanism was the most important factor in select-
ing the reconstruction method.4 An osteoarticular
allograft was performed if the rotator cuff and cap-
sule (and rarely the deltoid) were intact, and an
arthrodesis was performed if the rotator cuff, cap-
sule and/or glenoid surface were resected (Figs 1
and 2). If there was involvement of the scapula
including the glenoid with or without the proximal
humerus, a Tikhoff± Linberg procedure was per-
formed providing the neurovascular structures could
be preserved. The patients undergoing Tikhoff± Lin-
berg procedures were not included in this study.
Osteoarticular allogra ft
An osteoarticular allograft of appropriate size (size
match performed using standardized radiographs)
was chosen from the bone bank prior to surgery. All
allografts were harvested and stored according to the
standards of the American Association of Tissue
Bank8 and all grafts were treated with 2.5 megarads
of radiation following harvest. Osteoarticular allo-
grafts were thawed in the operating room and cut to
® t the humeral defect. Prior to ® xing the allograft to
host humerus, a rotator cuff repair was performed
Fig. 1. Anteroposterior plain radiograph of a 35-year-old man
4.5 years post-osteochondral allograft of the shoulder for a grade
2 chondrosarcoma.
Proximal humeral osteoarticular allografts versus arthrodeses 165
Fig. 2. Plain radiograph 2 years following allograft arthrodesis
for a grade 1 chondrosarcoma in a 19-year-old woman.
with the glenoid and acromion at thirty degrees
¯ exion, thirty degrees of abduction and thirty de-
grees of internal rotation.9,10 Soft tissues and carti-
lage were cleaned from the under-surface of the
acromion. A very long (18± 26 hole) 4.5 mm broad
plate was contoured to lie along the spine of the
scapula, over the acromion and down along the
allograft onto the patient’ s remaining distal hu-
merus. Interfragmentary compression screws were
used following provisional stabilization with K-wires
and passed through the plate and allograft, obtain-
ing purchase into the glenoid and neck of scapula.
Further interfragmentary screws were then passed
through the acromion into the graft to achieve ® rm
contact with the superior portion of the allograft
humeral head. A dynamic compression plating tech-
nique was then used to stabilize the distal osteotomy
between the allograft and the host humerus. Neu-
tralization of the reconstruction was accomplished
by insertion of screws through the plate into the
allograft and the scapular spine. Iliac crest bone
graft was packed around the proximal and distal
osteotomies.
Three arthrodeses were performed using a vascu-
larized ® bular graft instead of an allograft as each of
these had developed an infection; two following an
osteoarticular allograft (Fig. 3) and one following an
allograft arthrodesis. The infections were treated in
a two-stage process with removal of the allograft and
replacement with a cement spacer until the infection
cleared and then subsequent arthrodesis with the
vascularized ® bular graft. A broad plate was con-
toured along the spine of the scapula to the distal
humerus. A microvascular ® bula was harvested and
a hole was reamed in the glenoid where the ® bular
graft was slotted into place. The distal humerus was
also reamed and the ® bula was inserted about 2± 3
cm into the humerus. The ® bula was held in place
proximally by a single screw through the ® bula into
the glenoid. The plate was secured to the ® bula with
screws. The microvascular repair was then per-
formed with an end-to-side repair between the
brachial artery and vein and the peroneal artery and
vein. Iliac crest bone graft was applied at both
anastomosis sites.
A latissimus dorsi muscle ¯ ap was required in ® ve
of the eleven arthrodesis reconstructions to provide
complete soft tissue coverage over the graft site.
All patients in the osteoarticular and arthrodesis
groups received peri-operative antibiotics and were
immobilized in a Velpeau sling for 6 weeks. The
osteoarticular allograft patients were started on
physiotherapy at 6 weeks post-surgery with shoulder
shrugs and active-assisted forward ¯ exion exercises.
Their rehabilitation programs were progressed as
tolerated and according to radiographic evidence of
healing. The arthrodesis patients were started on
range of motion (ROM) exercises of the scapulotho-
racic joint when there was radiographic evidence of
healing of the glenoid osteotomy. All patients were
between the host and the allograft tendons using
non-absorbable sutures. A stable repair of the rota-
tor cuff was achieved in all cases. Fixation of the
allograft to host humerus was then performed using
a dynamic compression plating technique. Autograft
from the iliac crest was placed around the osteotomy
site in eight of the eleven cases. The insertions of the
latissimus dorsi and pectoralis major muscles were
repaired to the corresponding areas on the allograft
if possible. The biceps, brachialis and triceps were
advanced for soft tissue coverage of the allograft.
Arthrodesis
Eight of the eleven arthrodeses performed in ten
patients were achieved using allograft. The allograft
was prepared by osteotomizing the articular surface
so that the remaining humeral head was congruent
166 L. J. Probyn et al.
Fig. 3. Plain radiograph of a vascularized ® bular graft
arthrodesis 3 years after surgery to revise an infected osteoarticu-
lar allograft.
to function (activities of daily living, ADLs, leisure
activities, work, and pain levels.
Results
Oncologic results
There were seven males and four females who
underwent an osteochondral allograft, and their av-
erage age at surgery was 34 years (range, 10± 78
years). Seven of the patients had osteosarcoma (two
IB parosteal and ® ve IIB central osteosarcomas) and
four of the patients had chondrosarcoma (all IIB
lesions).14 Three males and seven females under-
went an arthrodesis (® ve of the ten after failed
osteoarticular allograft reconstruction). The average
age at surgery was 22 years (range, 12± 35 years). Of
the ® ve patients undergoing primary arthrodesis im-
mediately after tumour removal, three had a IIB
osteosarcoma, one a IB malignant giant cell tumour
and one a IB chondrosarcoma. Table 1 summarizes
the results.
The average length of bone resection was similar
for the osteoarticular allograft and arthrodesis
groups, 15.2 cm (range, 7.3 ± 25 cm) and 17.3 cm
(range, 7.5 ± 25 cm) respectively. Adjuvant treatment
varied depending on the grade and stage of the
tumour. For the osteochondral allografts, six of
eleven patients received chemotherapy. For the pri-
mary arthrodesis group, three of ® ve patients re-
ceived chemotherapy. None of the patients in the
study was treated with radiotherapy. Nine of the
patients undergoing osteoarticular allografts had
negative margins and two patients had positive mi-
croscopic margins. Four of the ® ve patients under-
going primary arthrodesis had negative margins and
one patient had positive microscopic margins.
At the time of the last follow-up, all of the pa-
tients who had an osteochondral allograft were alive
with no evidence of disease. One patient with os-
teosarcoma treated with an osteoarticular allograft
(negative margin surgery at initial operation) devel-
oped a high axillary nodal recurrence ten months
after initial resection. Fifty-three months after wide
resection of this nodal recurrence, the patient re-
mains disease-free. One osteosarcoma patient
treated by arthrodesis developed lung and pelvic
metastases eight months post-operatively and died
of disease at two years. This patient had positive
resection margins at the time of surgery but did not
develop a local recurrence. The other patients re-
constructed by arthrodesis were alive with no evi-
dence of disease.
Reconstructive results
Of the eleven patients who had an osteoarticular
allograft, ® ve patients required revision, all to a
glenohumeral arthrodesis. Two of these patients
sustained late infections (greater than six months
started on early gentle ROM exercises of the elbow,
wrist and hand.
Demographic, oncological outcome, treatment
complication and functional data at most recent
follow-up were collected for all patients. Function
was recorded using the Musculoskeletal Tumour
Society Rating Scale, 1987 version (MSTS, 1987),11
the Musculoskeletal Tumour Society Rating Scale,
1993 version (MSTS, 1993),12 and the Toronto
Extremity Salvage Score (TESS).13 The functional
data of the six patients, who had an osteoarticular
allograft (without revision to an arthrodesis), were
compared to the 10 patients who had an arthrodesis
using non-param etric statistics.
The ® ve patients who had a primary osteoarticu-
lar allograft and went on to a secondary arthrodesis
were interviewed and asked speci® c questions com-
paring the two different types of surgery with respect
Proximal humeral osteoarticular allografts versus arthrodeses 167
Fig. 4. Plain radiograph showing an atraumatic fracture of an
osteoarticular allograft 6 years post-operatively.
Of the ® ve patients who had a primary arthrode-
sis, four patients have had no complications. One
patient had a fracture of the allograft and developed
chronic infection which was treated with a cement
spacer and eventual microvascular ® bular graft
arthrodesis. Of the ® ve patients who had a second-
ary arthrodesis, three patients have had no compli-
cations. Two patients sustained non-unions which
healed after repeat bone grafting.
Functional data were availab le for all but one
patient with an osteoarticular allograft who did not
return for follow-up assessment. Mean follow-up
time was 45.6 months (range, 24± 81 months) for
the osteochondral allografts and 48.6 months
(range, 24± 132 months) for the arthrodesis patients.
Patients with a shoulder arthrodesis scored better in
all outcome measures. The mean scores for osteo-
chondral allografts and arthrodeses, respectively, for
the MSTS 1987 was 19.3 (range, 7± 27) and 21.1
(range, 17± 25), for the MSTS 1993 was 50 (range,
36± 70) and 68.2 (range, 53± 80) and for the TESS
score was 74 (range, 39± 95) and 78.5 (range, 42±
98). This difference was statistically signi® cant only
in the MSTS 1993 (p 5 0.001, Mann± Whitney U)
favouring improved function in the arthrodesis
group. The active range of motion achieved by the
two groups was especially striking. For all but one
patient who experienced chronic, debilitating pain
from an unstable osteoarticular reconstruction and
continued to experience some pain following con-
version to an arthrodesis, patients with an arthrode-
sis had better active forward ¯ exion (range 45± 85)
than any patient with an osteoarticular allograft
(range 30± 70). This was re¯ ected in the MSTS
1987 range of motion ratings in which no patient
with an osteoarticular allograft received more than
one of ® ve points whereas eight of the ten patients in
the arthrodesis group (® ve primary and ® ve second-
ary arthrodeses) received three of ® ve points for
range of motion.
The subjective description of the comparison of
the osteochondral allograft versus the arthrodesis
from the ® ve patients undergoing both surgeries
seemed to support the trend favouring arthrodesis
(see Table 2). Increased stability was noted after the
fusion. The pain was also reported as the same or
better after arthrodesis.
Discussion
It has been well documented that limb-salvage
surgery for tumours of the shoulder is an alternative
to amputation.4 Careful performance of the biopsy,
the use of neoadjuvant chemotherapy when indi-
cated and proper attention to complete surgical
resection of the tumour are essential in permitting
limb salvage without compromising tumour control.
Successful local resection, avoiding amputation
while controlling sarcoma, is demonstrated by the
post-surgery) and underwent staged salvage proce-
dures with removal of the osteochondral graft, im-
plantation of an antibiotic cement spacer and
subsequent reconstruction using a vascularized
® bula. Two patients with painful subluxation of the
shoulder and one patient with an osteoarticular allo-
graft fracture were also revised to an allograft
arthrodesis. The length of time between the osteo-
chondral allograft and the arthrodesis varied from
12 to 81 months (average 48.6 months).
Of the remaining six patients with osteochondral
allografts, one patient developed an inferior disloca-
tion of the allograft four months post-operatively.
This was stable and the patient did not want further
treatment despite limited glenohumeral motion.
One patient sustained a fracture of the allograft after
a fall and required replacement of the graft while
two patients developed a fracture of the allograft
without trauma. In one of these two patients, atrau-
matic fracture resulted in formation of callus around
the allograft fracture site with eventual stabilization
of the fracture, while the second patient is presently
awaiting revision. Two patients have not had
speci® c complications although one of these patients
has moderate to severe shoulder pain but does not
wish to undergo further surgery.
168 L. J. Probyn et al.
Table 1. Sample characteristics and outcom es
Osteochondral Arthrodesis
allograft* n 5 5 primaryn 5 11 n 5 5 secondary
Age (years) mean 5 33.6, sd 5 21.5 mean 5 22.4, sd 5 8.5Gender
Male 7 3Female 4 7
PathologyOsteosarcoma 7 7Chondrosarcoma 4 2Giant cell tumour 0 1
Adjuvant RxNone 5 6Pre-op chemo 1 0Post-op chemo 3 0Pre & Post-op chemo 2 4
MarginsNegative 9 9Positive 2 1
Bone resection(cm) mean 5 15.2, sd 5 4.5 mean 5 17.3, sd 5 5.1
ComplicationsNon-union 0 2Infection 2 1Fracture 4 1Subluxation/instability 3 0
Functional outcomeMSTS 1987 mean 5 19.3, sd 5 6.1 mean 5 21.1, sd 5 2.4MSTS 1993 mean 5 50.0,sd 5 9.8 mean 5 68.2, sd 5 7.7TESS mean 5 74.0, sd 5 23.5 mean 5 78.5, sd 5 19.2
Follow-up mean 5 45.6,sd 5 20.6 mean 5 48.6, sd 5 39.0
*Five patients with osteoarticular allografts were converted to arthodesis due tocomplications.
fact that there was only one nodal recurrence and
one systemic relapse in the patients in this study.
However, the choice of the best limb-reconstruction
method for tumours of the proximal humerus is a
dif® cult clinical decision.
In this study, patients were selected for osteoartic-
ular allograft reconstruction when suf® cient abduc-
tor musculotendinous tissue remained to provide a
stable soft tissue repair to the rotator cuff and
tendon of the allograft. Fusion was undertaken
when the osteoarticular allograft failed due to infec-
tion, instability or fracture, or if the glenoid bone
stock or soft tissues after resection were insuf® cient
to reconstruct a stable, mobile shoulder. In both of
these types of reconstructions, complications were
frequent and serious. In the osteoarticular group,
® ve have been revised to an arthrodesis: two for
infection, two for instability and one for fracture. In
the remaining six patients, three further fractures
were documented (one requiring allograft replace-
ment and one for which revision surgery is still
pending), one patient dislocated the shoulder and
one patient has chronic pain of moderate intensity.
In comparison, three of the ten arthrodeses were
complicated by non-union requiring repeat bone
grafting (n 5 2) and fracture/infection requiring a
staged microvascular ® bula arthrodesis.
The rates and types of complications experienced
by both the osteoarticular allograft and arthrodesis
patients in this study are similar to those reported by
other authors. Gebhardt et al.2 reported four com-
plications in three of seven patients undergoing
shoulder arthrodesis. These included a wound
slough, median nerve palsy and two patients with
prominent hardware. Layton et al.15 reported on
nine patients treated by shoulder arthrodesis. Two
patients died of metastases prior to healing of the
arthrodesis and there were complications consisting
of infection and fracture in four of the remaining
seven patients.15 Gebhardt et al.3 also reported on
twenty patients who underwent osteoarticular allo-
graft of the proximal humerus. In this group, one
had a non-union, four fractured and three became
infected.3 O’ Connor et al.4 reported osseous union
in all eight patients treated with osteoarticular allo-
graft, but four of these patients suffered collapse and
fracture of the subchondral region of the allograft. A
further patient suffered a fracture and required re-
vision to a second osteoarticular allograft. In the
same study, ten patients treated by arthrodesis de-
veloped one infection and two stress fractures.4
In the present study, the arthrodesis patients
tended to have higher scores on all functional mea-
sures although only the MSTS 1993 demonstrated a
Proximal humeral osteoarticular allogra fts versus arthrodeses 169
Ta
ble
2.
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pen
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170 L. J. Probyn et al.
statistically signi® cant difference between the two
clinical groups. The MSTS 1987 and the TESS
showed only a trend toward improved function in
the arthrodesis group. The lack of statistical
signi® cance in these two functional measures must
be considered in view of the small numbers of
patients in each treatment group as well as the
differences in the measures. The MSTS 1987 looks
at items that are likely to have low scores in both
groups (i.e. range of motion, strength, deformity).
Four of the six items of the MSTS 1993 are more
likely to vary amongst the two groups. These are
pain, function, emotional acceptance and lifting
ability, which were generally higher in the arthrode-
sis patients than the osteochondral allograft pa-
tients. There was less of a difference in hand
positioning and dexterity. With regards to the
TESS scores, most of the patients in both groups
were clustered around the mid to high range. This
means that all of the patients were able to do basic
activities of daily living (eating, bathing, grooming)
but experienced dif® culty performing high-level ac-
tivities such as sports, work, endurance and leisure
activities. Most of these patients also classi ® ed
themselves as `somewhat disabled’ .
Although the number of patients in the study
was relatively small and ® ve of the patients were in
both groups, there is a trend towards improved
function after an arthrodesis compared to an osteo-
chondral allograft. Subjective comparison also fa-
voured the arthrodesis. These results are similar to
those of O’ Connor in which patients treated with
primary arthrodesis had higher MSTS 1993 scores
than those reconstructed with osteoarticular allo-
grafts.4
The arthrodesis provides a stable shoulder girdle
with motion of the scapulothoracic joint to position
the arm in space.2 Subjective responses from pa-
tients in this study indicated a feeling of increased
stability and decreased pain after an arthrodesis
compared to an osteochondral allograft. These
qualitative responses were obtained from patients
who had undergone both procedures due to com-
plications from an osteoarticular allograft and were
based on patients remembering their `best’ function
after their osteoarticular allograft. These results
must be interpreted cautiously and in recognition
of all the biases imposed in the method.
It is recognized that this study did not include
patients with a prosthesis or allograft± prosthesis
composite as these reconstructive techniques have
not been utilized around the shoulder by our
group. Recent work by O’ Connor et al.4, however,
suggests that the complications and function in pa-
tients reconstructed with a prosthesis or allograft ±
prosthesis composite provides inferior results when
compared to an osteochondral allograft or
arthrodesis.
In conclusion, complications seemed to be more
apparent in patients undergoing osteoarticular allo-
graft. Patients treated with shoulder arthrodesis
tended to have better functional scores.
References
1 Frassica FJ, Sim FH, Chao EY. Primary malignantbone tumours of the shoulder girdle: Surgical tech-nique of resection and reconstruction. Am Surg 1987;53(5) ; 264± 9.
2 Gebhardt MC, McGuire MH, Mankin HJ. Resectionand allograft arthrodesis for malignant bone tumoursof the extremity. In: Enneking WF, ed. Limb salvage in
musculoskeletal oncology. New York: Churchill Liv-ingston, 1987 ; 567± 82.
3 Gebhardt MC, Roth YF, and Mankin HJ. Osteoartic-ular allografts for reconstruction in the proximal partof the humerus after excision of a musculoskeletaltumour. J Bone Joint Surg [Am] 1990; 72-A ; 334± 45.
4 O’ Connor MI, Sim FH, Chao EYS. Limb salvage forneoplasms of the shoulder girdle. J Bone Joint Surg[Am] 1996; 78-A ; 1872± 88.
5 Malawer MM, Sugarbaker PH, Lampert M, et al. TheTikhoff± Linberg procedure: report of ten patients andpresentation of a modi® ed technique for tumours ofthe proximal humerus. Surgery 1985; 97(5) ; 518± 28.
6 Malawer MM. Tumours of the shoulder girdle. Tech-nique of resection and description of a surgicalclassi® cation. Clin Orthop 1991; 22(1) ; 7± 35.
7 Enneking WF, Dunham W, Gebhardt M, MalawerM, Pritchard D. A system for the classi® cation ofskeletal resections. Chir Og M ov 1990; 75(Suppl.1) ; 217± 40.
8 Friedlaender GE, Mankin HJ, Sell KW. Osteochondralallografts. Biology, banking and clinical applications.Boston: Little Brown and Company, 1983.
9 Hawkins RJ, Neer CS. A functional analysis of shoul-der fusions. Clin Orthop 1987; 223 ; 65± 76.
10 Richards RR, Sherman RM, Hudson AR, Waddell JP.Shoulder arthrodesis using a pelvic-reconstructionplate. A report of eleven cases. J Bone Joint Surg [Am]
1988; 70-A ; 416± 21.11 Enneking WF. Modi® cation of the system for func-
tional evaluation in the surgical management of mus-culoskeletal tumours. In: Enneking WF ed. Limb
salvage in musculoskeleta l oncology. New York:Churchill Livingston, 1987 ; 626± 39.
12 Enneking WF, Dunham W, Gebhardt MC, et al. Asystem for the functional evaluation of reconstructiveprocedures after surgical treatment of tumours of themusculoskeletal system. Clin Orthop 1993; 286 ; 24±246.
13 Davis AM, Wright JG, Williams JE, et al. Develop-ment of a measure of physical function for patientswith bone and soft tissue sarcoma. Quality of LifeResearch 1996; 5 ; 508± 16.
14 Enneking WF, Spanier SS, Goodman MA. A systemfor the surgical staging of musculoskeletal sarcoma.Clin Orthop 1980; 153 ; 106± 20.
15 Layton T, Scarborough M, Vander Griend, RA. Allo-graft arthrodesis of the shoulder following resection ofthe proximal humerus. Contem porary Orthopaedics1994; 29(6) ; 421± 26.
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